Patient preferences for the integration of mental health counseling and chronic disease care in South Africa

Bronwyn Myers,1,2 John A Joska,3 Crick Lund,4,5 Naomi S Levitt,6 Christopher C Butler,7 Tracey Naledi,8,9 Peter Milligan,10 Dan J Stein,11,12 Katherine Sorsdahl4 1Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, Cape Town, South Africa; 2Division of Addiction Psychiatry, Psychiatry and Mental Health, 3HIV and Mental Health Research Unit, Division of Neuropsychiatry, Department of Psychiatry and Mental Health, 4Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa; 5Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK; 6Division for Diabetes and Endocrinology, Department of Medicine, University of Cape Town, Cape Town, South Africa; 7Nuffield Department of Primary Care Health Services, Oxford University, Oxford, UK; 8Western Cape Department of Health, Cape Town, South Africa; 9Faculty of Health Sciences, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa; 10KwaZulu-Natal Department of Health, KwaZulu-Natal, South Africa; 11Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa; 12SAMRC Unit on Anxiety and Stress Disorders, Cape Town, South Africa Purpose: To describe patient perceptions of the acceptability of integrating mental health counseling within primary care facilities in the Western Cape province of South Africa and their preferences for the way in which this care is delivered. Patients and methods: Qualitative interviews with 30 purposively selected patients receiving treatment for HIV or diabetes within primary care facilities who screened positive for depression using the Center for Epidemiological Studies Depression Scale or hazardous alcohol use through the Alcohol Use Disorders Identification Test. Results: Participants articulated high levels of unmet need for mental health services and strong associations between poor mental health and the challenges of living with a chronic disease. Consequently, they considered it acceptable to offer screening and mental health counseling within the context of chronic disease care. They thought counseling would be highly relevant if it helped patients develop adaptive strategies for coping with stress and negative emotions. Irrespective of chronic disease, patients indicated a preference for lay counselors rather than existing clinicians as potential delivery agents, supporting a task-shared approach to mental health counseling delivery in primary care settings. Some expressed concern about the feasibility of using lay counselors already present in facilities to deliver this service, suggesting that additional counselors might be needed. Conclusion: Findings demonstrate a need for mental health counseling within the context of chronic disease care in South Africa. Task-shared approaches, using lay counselors, seem acceptable to patients – provided counselors are selected to ensure they possess the qualities associated with effective counselors. Findings have informed the design of a task-shared mental health program that is responsive to the preferences of patients with chronic diseases. Keywords: integration, mental health, chronic disease care, counseling preferences, primary health care, South Africa, global mental health, task sharing, alcohol, depression